MSC - F. Surgery Answers 2025

Prognosis

Generally good with early diagnosis and proper surgical treatment

Delayed treatment → high risk of complications and mortality

16.Hernias of the esophageal foramen of the diaphragm. Classification, clinic, diagnosis, surgical treatment

Hiatal hernias refer to the herniation of abdominal contents—primarily parts of the stomach—into the thoracic cavity through an enlarged esophageal hiatus of the diaphragm. They account for over 90% of diaphragmatic hernias and are a common upper GI disorder.

Classification

1.Sliding (Axial) Hiatal Hernia – ~95% of cases

The gastroesophageal junction (GEJ) and a portion of the stomach slide into the thorax.

Subtypes (B.V. Petrovsky):

o Cardiac

o Cardiofundal

o Subtotal gastric

oTotal gastric

Can be fixed or non-fixed (reduces when upright).

2.Paraesophageal Hernia – ~5% of cases

GEJ remains in place; part of the stomach (e.g., fundus or antrum) herniates through the hiatus.

Risk of incarceration and strangulation.

Types:

oFundal

o Antral

o Intestinal

o Intestinal-gastric

o Glandular

Etiology and Pathogenesis

Congenital: Weakness or maldevelopment of the esophageal hiatus.

Acquired:

o Weakening of phrenoesophageal membrane

o Widening of the hiatus

oIncreased intra-abdominal pressure (obesity, pregnancy, heavy lifting)

Mechanisms:

oPulsion (↑ intra-abdominal pressure)

o Traction (esophageal shortening from spasm/inflammation)

Clinical Features

Sliding Hernias (Axial)

Often symptomatic due to gastroesophageal reflux.

Symptoms:

o Epigastric/substernal pain (postprandial, worsens on lying down) o Heartburn

o Regurgitation

o Dysphagia (intermittent)

oExtraesophageal symptoms: hoarseness, chronic cough, aspiration

Complications:

o Reflux esophagitis

o Esophageal stricture

o Barrett’s esophagus (precancerous)

o GI bleeding

Paraesophageal Hernias

Usually asymptomatic early.

Symptoms when present:

o Postprandial fullness, pain

o Dysphagia

oOccasional vomiting

Complications:

oGastric volvulus

o Incarceration

o Strangulation

Diagnosis

1. Radiology (mainstay):

Barium swallow (esophagography):

o Sliding: GEJ above diaphragm; widening of hiatus; reflux.

oParaesophageal: Intrathoracic stomach with GEJ below diaphragm.

2.Endoscopy (EGD):

Confirms presence of hernia

Evaluates esophagitis, Barrett’s esophagus, mucosal changes

3.Manometry and 24-hour pH monitoring:

Assesses LES function and reflux severity.

Treatment

Sliding Hernias

Conservative (first-line):

Lifestyle changes: weight loss, head elevation during sleep, avoiding meals 3–4h before bed

Pharmacological:

o PPIs or H2 blockers

oProkinetics

Surgical Indications:

oRefractory GERD

o Complications (stricture, ulcer, bleeding, Barrett’s)

oLarge hernia with symptoms

Surgical Technique:

oNissen fundoplication: 360° wrap of gastric fundus around the lower esophagus

o Performed open or laparoscopically

Paraesophageal Hernias

Surgical treatment is always indicated due to risk of strangulation.

Hernia reduction

Closure of the diaphragmatic defect

Antireflux procedure (often Nissen fundoplication)

17.Paraesophageal hernia, clinic, diagnosis, treatment

A paraesophageal hernia is a type of hiatal hernia where part of the stomach herniates into the thoracic cavity through the esophageal hiatus, but the

gastroesophageal junction (GEJ) remains in its normal intra-abdominal position. It accounts for approximately 5% of all hiatal hernias.

Clinical Features (Clinic)

Asymptomatic phase:

Many patients are incidentally diagnosed during investigations for other reasons.

Symptomatic phase:

Postprandial epigastric or retrosternal pain (due to compression or volvulus)

Early satiety and bloating

Dysphagia (from mechanical obstruction)

Nausea or vomiting

Belching or regurgitation

Symptoms may worsen in supine position

Complications (may be the first presentation):

Incarceration (fixed, irreducible hernia)

Strangulation (compromised blood supply; surgical emergency)

Gastric volvulus

Ulceration and bleeding (Cameron ulcers)

Perforation

Iron-deficiency anemia (chronic blood loss)

Diagnosis

1.Chest X-ray (plain film)

May show retrocardiac air-fluid level (gastric bubble in thorax)

2.Barium swallow (contrast esophagography)

Gold standard

Shows gastric fundus or body herniated into thorax with normal GEJ position

3.Esophagogastroduodenoscopy (EGD)

Helps rule out esophagitis, ulcers, Barrett’s esophagus

Confirms intrathoracic position of stomach

4.CT scan of chest/abdomen

Used in complicated cases to evaluate anatomy and complications like volvulus or strangulation

Treatment

Indication: Always surgical

Due to risk of incarceration and strangulation

Surgical Objectives:

1.Reduction of the herniated stomach into the abdomen

2.Resection of hernia sac if present

3.Closure of the diaphragmatic hiatus

4.Antireflux procedure (e.g., Nissen fundoplication) if cardia function is impaired or hiatal defect is wide

Surgical Techniques:

Laparoscopic paraesophageal hernia repair (standard of care)

Open surgery in complicated or large hernias

Mesh reinforcement may be used if defect is large

In emergencies (e.g., strangulation or perforation):

Immediate surgery with resection of necrotic stomach if needed

18. Diaphragmatic hernias, predisposing and productive factors, clinical symptoms, diagnostic methods. Rare types of hernias of natural orifices of the diaphragm.

A diaphragmatic hernia refers to the protrusion of abdominal organs into the thoracic cavity through either a natural or pathological opening in the diaphragm.

Classification:

By Etiology:

1. Congenital

o False congenital hernias (e.g., Bochdalek and Morgagni hernias)

o True hernias of weak zones

o Hernias through natural orifices (hiatus, aortic, IVC)

oHernias of atypical localization

2.Acquired

oTraumatic (blunt or penetrating injuries)

o Non-traumatic (e.g., age-related, degenerative)

By Presence of Hernial Sac:

True hernia – with sac

False hernia – without sac (commonly traumatic)

Rare Types (Natural Orifices of Diaphragm):

Hiatal hernia (most common of this group)

Hernia through inferior vena cava opening

Hernia through aortic opening

Hernia through sympathetic nerve slits

These are exceedingly rare and of limited clinical significance except hiatal hernias.

Predisposing and Producing Factors:

Predisposing Factors:

Congenital defects (e.g., non-closure of pleuroperitoneal canals)

Weakness of connective tissue

Degenerative changes in the diaphragm

Previous trauma

Chronic illnesses affecting diaphragm tone

Producing (Triggering) Factors:

Increased intra-abdominal pressure:

o Heavy lifting

o Chronic coughing

o Constipation

o Pregnancy

o Obesity

o Overeating

Clinical Features:

Symptoms due to Herniated Contents:

Epigastric/chest pain

Postprandial dyspnea

Palpitations

Regurgitation/vomiting after meals

Early satiety

Diaphragmatic eventration

Left lower lobe pneumonia

Pleural effusion

Mediastinal mass

Myocardial infarction (in strangulated cases)

Acute abdomen (pancreatitis, cholecystitis)

Complications:

Strangulation

Gastrointestinal bleeding

Perforation

Respiratory distress

Chronic pain or obstruction

Recurrent hernia after surgery

Treatment:

General Principles:

All diaphragmatic hernias require surgical repair, except some sliding hiatal hernias managed medically.

Surgical Approaches:

Elective Surgery – abdominal approach for uncomplicated hernias

Emergency Surgery – thoracic or thoracoabdominal approach for strangulated or traumatic hernias

Surgical Steps:

1.Reduction of herniated contents

2.Excision of hernial sac (if present)